Semmelweis University

Department of Traumatology

Dr. Gál Tamás

Management of open fractures. Septic and

non-septic complications in Traumatology.

Fractures of the tibia and fibula.

Fractures of the Tibia Anatomical characteristics:

• Anteromedial surface: thin soft tissue

coverage open fractures (13%)

• Osteo-fascial muscle compartments

compartment syndroma (≤ 20%)

• Dynamic framework

• Tension between tibia and fibula

• 1/6th of the load on the fibula

• Elastic load absorption

AO

Arbeitsgemeinschaft für

Osteosynthesefragen

Conservative treatment

• Stable, non-dislocated fractures

• General condition of the patient

Traction for 3 weeks…

Cast: 9-12 weeks

Operative treatment

• Intramedullary nailing

• Plate synthesis

• External Fixator

Indications of intramedullary nailing

for the treatment of tibia fractures

• Best choice for fractures between the 2/7-6/7th

(shaft fractures) if it can be technically carried out

• Reamed nailing: monotrauma, patient is allowed to

bear weight earlier, good for cases of mal-union or

non-union

• Unreamed nailing: polytrauma, shorter operation

time, Grade lll- types B-, C open fractures, narrow

intramedullary canal.

• Interlocking: gives rotational stability, static

interlocking recommended, dynamisation can be

later performed. Mandatory in unreamed nailing.

Reamed Intramedullary Nailing

Unreamed intramedullary nailing – UTN

(Unreamed Tibia Nail)

IM nailing post operative care:

•if stability of the fracture is in question, then below knee cast

immobilization and touch down wt bearing are used until healing

•once partial fracture healing has taken place, consider a functional brace

or consider a below knee cast.

•active dorsiflexion and plantarflexion stresses the tibia and produces

displacements similar to wt bearing;

- static locking: most tibial fractures heal in the static locked mode;

- dynamization:

- removal of proximal or distal screws allows axial loading of tibia

- consider at 3 months in axially stable fractures with no callus

- axially unstable frx should remain in static mode and should receive bone

graft

Indications of plate synthesis

• Intraarticular fractures and fractures near

the joint (when ORIF is necessary)

• Non-union, malunion (with bone graft)

• When other methods of treatment are

contraindicated (e.g. compartment

syndrome)

Plate synthesis

Medial plate

Indications for External Fixation

• Severe soft tissue injury (Glll-BC) OPEN FRX

• In certain cases of polytraumatisation

• For intermittant limb shortening

• As a supplementation for minimal

synthesis epi-metaphyseal fractures

• Joint bridging

• Segment transfer, bone lengthening

External fixation device

Ilizarov external fixation device

Compartment syndrome

increasing tissue pressure prevents

capillary blood flow and produces

ischemia in muscle and nerve tissue. The

process is progressive and leads to

necrosis with permanent loss of function!

Surgical Emergency…..

Otherwise amputation

Intracompartmental pressure > 30 mmHg

Causes • High-energy limb injuries (most

often calf area)

• Crushing injuries

• Burns

• Prolonged compression (comatose,

unprotected patient)

• Abnormal capillary permeability

caused by reperfusion after

prolonged ischemia. Tight

bandages, splints, or

casts….Volkmann ischemic

contracture

Compartment syndrome

• Edema

• Pallor

• Pain „like childbirth”

• Pain to Passive

movement

• Local hyp/Paraesthesia

• Paresis

• Pulselessness

FASCIOTOMY !!!

Open fractures – Gustillo and

Anderson classification

55 y.o. male pedestrian was hit by an automobile.

Patient is HIV positiv. Grade I intraart. open tibia frx

Intraop. imaging

Postop. 12 weeks

Breakage of the 4

proximal screws

-8 weeks non-wt. bearing

- week 8-12 phys. ther.

(imitation of walking)

-12 th week – half wt bearing

-pain in the area of the op.

-Another op

-7 extra screws

-callus formation

-postop 24 th week

jogging again

-fully recovered,

metal removal after

2 years

INFECTION: the most serious complication for

both the patient and the doctor!

• Contamination

bacteria on site

* bakterial culture

* temperature

drain-cultures

germs ↑

immune status ↓

• Infection

signs of bacterial inf.

* rubor (hyperemia)

* tumor (edema)

* calor (warm)

* dolor (painful)

* functio laesa (loss of

function

* pus

Causes of infection

• Open wounds / fractures

• Iatrogenic infections

- sterility problem

- ultrasterile boxes

• Circulation problems, diabetes

• Immune status

- transplants / steroids

- oncologic illness

• Operative errors

- haematomas, tissue damage

Classification of infections 1.

• Acute

- early posttraumatic period (1-7 days)

• Subacute

- (1 week- 1 month)

• Chronic

- (after 1 month)

Classification of infections 2.

• superficial

- skin necrosis

- epifascial supp.

good prognosis!

• deep

- subfascial

- intraarticular

- tendovaginal

- body cavity

- peri-implant

bad prognosis!

Superficial infection

• Diagnostics

- inspection

- palpation

- Ultrasound

- lab results

• Therapy

- conservative/kryoth.

- operative (revision,

debridement, perhaps

drainage)

Deep infection

• Diagnostics

- inspection

- palpation

- Ultrasound

- aspiration

- labs

• Therapy

- immediate revision,

debridement

- suction drainage

(vaccum sealing)

- perhaps Septopal chain

or antibiotic cement

Subfascial, extra/intraarticular

haematoma, tissue damage

Diagnostic methods

• Laboratory

- WBC

- qualitative blood

- We (Erythrocyte Sedimentation Rate)

- CRP

- procalcitonin

- TNF

• Instrumental

diagnostics

- sonography (punction)

- x-ray (gas, fluid)

- CT/contrast

- MRI/contrast

- scintigraphy

- thermography (?)

•obtain adequate cultures •Antibiotics should be considered only if the patient is systemically septic prior to wound exploration •Empirical antibiotic treatment is based upon the antibiotics sensitivities of likely infecting organisms

• history of previously positive cultures

• institutional frequency statistics

Antibiotic beads

Locally administered antibiotics may

have a supplementary role in the

management of musculoskeletal

infections.

poorly perfused areas, or “dead space”,

antibiotic-laden cement is frequently

used, both to fill the space and to

deliver high doses of local antibiotic

with low risk of systemic toxicity.

A common technique is the use of

antibiotic-laden PMMA beads.

Antibiotic-impregnated beads may

be purchased in some countries or

made by the surgeon more cheaply.

Circulation problem

Contraindication

profylaxis: Radical debridement

Pathophysiology

Sequester

Area outside of

circulation

ANTIBIOTICS parenteral / local

Time factor!

SEPTOPAL-prophylaxis

Open fracture prophylaxis

Magyar Traumatologia 28:280 (1985)

Local AB-therapy:

Protection of

osteosynthesis

under fracture

healing

Local AB-therapy

Local AB-therapy:

Fill area, ASP

preparation

Soft tissue-correction

Without debridement

local AB-treatment is

useless, contraindicated!

Disadvantage:

resistency

Intramedullary debridement

Intramedullary debridement

gravitational

drainage

intermittant

removal

Septic complication after femoral neck OS

Early

debridement,

2 session

TEP implant.

GIRDLESTONE hip

42

éves chr.

alc.

GIRDLESTONE-hip

Limb salvage

9 y.o. girl

Brain contusion

Rupture of stomach

Closed tibia frx

(car accident)

„Second look”

Patient fell from a ladder, open distal

intraart frx of tibia and fibula

Angular plate synthesis

Osteomyelitis

Local

antibiotic

cement

Total Knee Replacement – 60 y.o.

male farmer

3 months postop.

Antibiotic spacer

7 months postop.

Revision TKR

•10 months postop

•Signs of loosening

again

11 months postop.

AB spacer again

15 months postop.

Revision surgery again

Non-union

-34 year old

male was in a

fight, and

defended

himself with his

right foremarm

-ulna diaphysis

fracture

Postoperative x-ray

Postop. 3 months

Bone graft

Thank you for your attention